Updated Estimates of Childhood Diarrheal Morbidity in 11 Sub-Saharan African Countries Using the Latest Demographic and Health Surveys (2021-2024): A Multilevel Modified Poisson Regression Analysis.

backgroundDiarrheal disease remains a leading cause of morbidity among children under 5 years of age in sub-Saharan Africa, yet many estimates rely on outdated data. Using the most recent Demographic and Health Survey (DHS) datasets, this study is aimed at providing updated estimates of childhood diarrheal morbidity and at identifying associated factors to inform monitoring and targeted interventions.

methodsThis study analyzed pooled DHS data collected between 2021 and 2024 from 11 sub-Saharan African countries, focusing on diarrheal morbidity among 124,167 children under 5 years of age. A multilevel modified Poisson regression model was employed to estimate adjusted prevalence ratios (APRs) and corresponding 95% confidence intervals (CIs), accounting for the hierarchical structure of the data, including clustering at household and community levels. Statistical significance was declared at p < 0.05.

resultsThe prevalence of diarrheal morbidity among children under 5 years of age was 13.8% (95% CI: 13.6%-14.0%), with significant variation across the included sub-Saharan African countries. Lower prevalence was observed among children born to mothers aged 25-34 years (APR = 0.89; 95% CI: 0.85-0.92) and 35-49 years (APR = 0.82; 95% CI: 0.78-0.86), female children (APR = 0.93; 95% CI: 0.91-0.96), children aged 37-59 months (APR = 0.42; 95% CI: 0.40-0.44), children of literate mothers (APR = 0.86; 95% CI: 0.82-0.89), those from wealthier households (APR = 0.84; 95% CI: 0.79-0.88), children covered by health insurance (APR = 0.89; 95% CI: 0.83-0.95), and those who had received measles vaccination (APR = 0.95; 95% CI: 0.90-0.99). Conversely, distance to health facilities as a big problem (APR = 1.09; 95% CI: 1.05-1.13), underweight status (APR = 1.17; 95% CI: 1.10-1.24), and wasting (APR = 1.17; 95% CI: 1.09-1.26) were associated with a higher prevalence of diarrheal morbidity. Positive associations were also observed for media exposure, improved toilet facilities, four or more antenatal care visits, postnatal checkups, vitamin A supplementation, rotavirus vaccination, and deworming treatment. These associations should be interpreted cautiously, as they are unlikely to be causal and may reflect reverse causation, residual confounding, or reporting and detection bias.

conclusionChildhood diarrhea remains a major public health concern in sub-Saharan Africa, with substantial variation across the included countries. Diarrheal morbidity among children under 5 years of age was associated with a range of biological, socioeconomic, nutritional, and health service-related factors. Lower diarrheal morbidity was associated with older maternal age, female sex, older child age, maternal literacy, higher household wealth, health insurance coverage, and measles vaccination, whereas undernutrition and barriers to healthcare access were associated with higher morbidity. Counterintuitive associations observed for several health service and infrastructure variables likely reflect reverse causation and reporting bias rather than harmful effects. These findings underscore the need for integrated interventions aimed at improving child nutrition, reducing socioeconomic inequalities, and expanding equitable access to quality healthcare services.